Dialectical Behavior Therapy

Adherence Checklist for Individual Therapy

(DBT AC – I)
Training Manual
(Harned, Schmidt, & Korslund, 2021)

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OVERVIEW

The Dialectical Behavior Therapy Adherence Checklist for Individual Therapy (DBT AC-I) has been
developed as a brief, pragmatic measure to facilitate implementation and dissemination of DBT and
guide quality improvement efforts in routine practice settings. The measure is used to rate the extent to
which a single individual therapy session resembles DBT as it is defined in the treatment manual
(Linehan, 1993). The DBT AC-I includes 26 items that were empirically derived from the 66-item DBT
Adherence Coding Scale (DBT ACS; Linehan & Korslund, 2003), the gold standard observer-rated
measure of adherence to DBT. The DBT AC-I draws from all 12 categories of major therapeutic strategies
included in the DBT ACS but is not meant to be a complete list of all strategies, procedures, and
protocols utilized in DBT. The DBT AC-I can be completed by therapists as a self-report measure to
evaluate their own delivery of DBT and/or by observers (e.g., supervisors, team members, consultants)
to evaluate another therapist’s delivery of DBT.

Guidelines for Rating

The DBT AC-I should be completed as soon as possible after conducting or reviewing the individual
therapy session. The person completing the DBT AC-I should keep in mind the entirety of the session
when rating each item. Each item represents a strategy in DBT and is rated on a binary scale where a
score of “1” is considered adherent and a score of “0” is considered non-adherent. For each item,
behavioral anchors are provided for “1” and “0” that specifically define adherent and non-adherent
delivery of that strategy. Of the 26 strategies, 11 are required in every session and 2 are required in
every session after pre-treatment. Required strategies are labeled as such, both in this manual and in
the DBT AC-I, where they are identified with either an asterisk (*required in every session) or a double
asterisk (**required in every session after pre-treatment). The remaining 13 items are required only if
certain conditions are met and use “if-then” rules for rating (e.g., if the client attempted suicide since
the last session, then the suicidal behaviors protocol is required). Information about the conditions
under which these contextual strategies are required is included in this manual and in the DBT AC-I
behavioral anchors.

For each item, you will first need to decide if the strategy was used. Then you will need to consider the
following when rating each item:

1. If the strategy was used, was it done sufficiently (e.g., in terms of frequency, duration, and
execution) given the context of the session?
➢ If a strategy was used and done sufficiently, it is rated as adherent (1).
➢ If a strategy was used but not done sufficiently, it is rated as non-adherent (0).

2. If the strategy was not used, was it needed either because it is a required strategy or the
context of the session necessitated it?
➢ If a strategy was not used and it was not needed, it is rated as adherent (1).
➢ If a strategy was not used and it was needed, it is rated as non-adherent (0).

It is important to note that it is possible to achieve a “1” (adherent) rating even if the strategy could
have been done more thoroughly and/or with a higher degree of competence. A score of “1” simply
indicates that a strategy was done sufficiently to meet the threshold for adherence as per the
operational definitions provided in this manual, or was not used when not needed. Thus, a score of “1”

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does not necessarily mean that the strategy was delivered in an ideal manner and there may still be
room for improvement.

DBT AC-I Versions

A therapist self-report and an observer-rated version of the DBT AC-I are available. In addition, each
version has a basic and extended option. The basic option includes the 26 primary items as well as 3
overall evaluation items. The extended option adds text boxes after each of the 26 primary items to
provide space for comments (e.g., to explain why the strategy was rated as adherent or non-adherent).
Psychometric Properties
To date, the psychometric properties of the therapist self-report and observer-rated versions of
the DBT AC-I have been evaluated in a sample of 50 therapist-client dyads engaged in DBT in routine
practice settings (Harned, Schmidt, Korslund, & Gallop, in prep). In this study, therapists were trained to
use the DBT AC-I by reading a training manual and then rating their delivery of DBT in two consecutive
sessions. The sessions were also rated by observers who had been trained to reliability in the gold
standard DBT Adherence Coding Scale (DBT ACS; Linehan & Korslund, 2003). The primary psychometric
indices that were evaluated include: (1) inter-rater reliability (i.e., the degree of agreement between
raters), (2) convergent validity (i.e., the degree to which the DBT AC-I was correlated with the gold
standard DBT ACS), and (3) criterion validity (i.e., the degree to which the DBT AC-I correctly identified
adherent vs. non-adherent sessions as defined by the gold standard DBT ACS).
Therapist self-report. Therapists reported that it took them an average of 26.2 minutes (SD =
19.2) to complete the DBT AC-I. Therapists rated the DBT AC-I as having above average usability and the
manual as being very helpful as a method of training them to complete the DBT AC-I. The average item-
level agreement rate between therapists and trained observers was 84.2% (range = 63.0% - 98.0% across
items). Inter-rater reliability between therapists and trained observers was very good for 56% of the
items, good for 28% of the items, and moderate for 16% of the items. Given the variability across items,
the inter-rater reliability for the DBT AC-I total score (sum of all items) was poor (ICC = 0.09).
Additionally, therapists’ self-rated scores on the DBT AC-I had poor convergent and criterion validity
with the observer-rated DBT ACS, the gold standard measure of adherence to DBT. Specifically,
therapists’ scores on the DBT AC-I were not correlated with the DBT ACS computed global score and did
not significantly differentiate between adherent versus non-adherent sessions. Taken together, this
indicates that therapists’ self-rated adherence on the DBT AC-I should not be assumed to reflect their
actual adherence to DBT. Importantly, this finding is not unique to this measure or to DBT. Across
treatments, therapists often have trouble accurately reporting on their own sessions for reasons that
are understandable (e.g., retrospective recall vs. watching a session; less training in adherence rating).
In an effort to provide additional guidance on how to rate items that had lower reliability, the
results of this study were used to inform additional revisions to the DBT AC-I and this manual. The
revisions were reviewed by DBT experts before finalizing the measure and manual for dissemination.
Additional research is needed to evaluate if these revisions and/or other methods of training therapists
to rate their own adherence may improve the reliability and validity of the therapist self-report version
of the DBT AC-I.
Trained observers. In contrast, the DBT AC-I was found to have excellent psychometric
properties when used by trained observers. Inter-rater reliability between trained observers and the
gold standard rater of the DBT ACS was excellent for the DBT AC-I total score (ICC = 0.93). Additionally,
the observer-rated DBT AC-I total score had high convergent validity with the computed global score of
the DBT ACS (r = 0.90, p < .001). The observer-rated DBT AC-I also had strong criterion validity in
classifying adherent versus non-adherent sessions. Specifically, a cut-off score of 23 (out of 26) on the

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DBT AC-I correctly identified 91.1% of adherent sessions and 80.0% of non-adherent sessions as defined
by the DBT ACS computed global score. In sum, the DBT AC-I offers an efficient and effective alternative
to the DBT ACS that can be used to formally assess adherence to DBT when rated by observers who have
been trained to reliability in the DBT ACS. However, its reliability and validity when used by other types
of observers (e.g., supervisors, team members, or consultants without training in the DBT ACS) has not
yet been evaluated.
Scoring the DBT AC-I
Therapist and untrained observer raters. Given that therapists were generally found to have
difficulty generating reliable or valid scores on the DBT AC-I, if a total score is computed based on
therapist self-report it may be imprecise and/or inaccurate. In addition, the psychometric properties of
the DBT AC-I have not yet been evaluated among observers who were not already trained in the DBT
ACS. Therefore, scores generated by therapists and/or observers not trained in the DBT ACS should not
be interpreted as being indicative of therapists’ actual adherence to DBT, but can be used for other
lower stakes purposes (see below).
Trained observer raters. If observers have been formally trained to reliability on the DBT ACS, a
reliable and valid total score can be computed by summing the 26 items (possible range = 0-26). A total
score of 23 or higher can be considered “adherent” and used for higher stakes purposes (see below).
Recommended Uses of the DBT AC-I
Based on the available research, the recommended uses of the DBT AC-I are described below.

Therapist Untrained Trained

Potential Use Description Self-Report Observers Observersb
a

Quality Use to monitor the quality of DBT that is being

Monitoring delivered by a therapist or in a program.
Use the evaluation results to help therapists
Quality
modify and improve their delivery of DBT
Improvement
when needed.
Supervision Use to inform supervision and identify
and Training additional therapist training needs.

Team Use to obtain/provide consultation during

Consultation DBT team meetings.

Formal Use to make reliable and valid determinations

Assessment of the degree to which sessions were
of Adherence adherent to DBT.
Use in situations in which the evaluation
results could have serious negative impacts on
High Stakes
the therapist or program being rated (e.g.,
Decisions
decisions related to salary and promotion,
service contract loss, certification).
a
Observers who have not been trained to reliability in the gold standard DBT Adherence Coding Scale.
b
Observers who have been trained to reliability in the gold standard DBT Adherence Coding Scale.

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How to Use this Manual
• We strongly suggest reading through the entire manual prior to using the DBT AC-I.
• Strategies are grouped by category. Chapters and page numbers refer to the DBT treatment
manual (Linehan, M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York: Guilford Press) and are provided for therapists who would like to review additional
information about a specific strategy.
• Examples are meant to be illustrative rather than exhaustive; that is, given that DBT is a
principle-based treatment, there are numerous ways in which each strategy could be delivered
with and without adherence that include, but are not limited to, the examples provided.
• Throughout the manual, the following abbreviations are used: T = therapist and C = client.

Citation

Harned, M. S., Schmidt, S. C., & Korslund, K. E. (2021). The Dialectical Behavior Therapy Adherence
Checklist for Individual Therapy (DBT AC-I). https://www.dbtadherence.com/

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I. STRUCTURAL STRATEGIES (Chapter 14 pp. 437 – 461)

1. DIARY CARD (p. 452)

**Required in every session of individual DBT after pre-treatment

The essence of this item is that the T reviews and conveys the importance of the diary
card and C’s progress since the last contact.

Adherent (1): The diary card should be collected and the information (e.g., target behaviors,
emotions, skills) tracked on the diary card should be reviewed out loud and used to inform the
session agenda. If the C did not complete the diary card, it should either be filled out in session, or
the T should ask about target behaviors and skills practice since the last session. If the client is still in
pre-treatment and has not yet begun to complete a diary card, this strategy would not be needed
and would thus be coded as adherent.

Non-adherent (0): If the T does not ask for the C’s diary card, or if the T looks at the C’s diary card
but does not comment on the information on the card or use it to structure the session agenda, this
item would fall below adherence. Additionally, this item would fall below adherence if the diary card
is not completed prior to session and the T does not ask the C to fill it out in session and/or does not
ask about target behaviors and skills practice since the last session.

2. ORGANIZE BY TARGETS (p. 453)

*Required in every session of individual DBT

The essence of this item is that the T structures the session time in accordance with the
target hierarchy for the C’s stage of treatment.

Adherent (1): Session time is organized according to the primary behavior targets for the C’s stage
of treatment. In Stage 1 of DBT, the target hierarchy for individual therapy is as follows: 1) Life-
threatening behavior; 2) Therapy-interfering behavior; 3) Quality-of-life-interfering behavior; 4) DBT
skills. Structuring the session in accordance with the target hierarchy does not mean that the T
spends the whole session on the highest priority target, nor does it mean that targets need to be
addressed in the same order as the target hierarchy (e.g., first talking about life-threatening
behavior before talking about therapy-interfering behavior). Rather, it means that the time spent on
each target should reflect its current importance in the context of the therapy session.
Non-adherent (0): This item would be rated as non-adherent if the T did not address the highest
priority targets at all (e.g., life-threatening behavior occurred but was not targeted) or insufficient
time was spent on the highest priority targets (e.g., because too much time was spent on lower
priority targets). For example, if C has missed three consecutive skills groups and the T spends nearly
all of the session discussing an argument the C had with their friend and reserves only a few minutes
at the end of the session to address the C’s significant therapy-interfering behavior, this would be
non-adherent organizing by targets.

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3. EMOTION FOCUS
*Required in every session of individual DBT

The essence of this item is that the T focuses on the C’s emotions throughout the
session.

Adherent (1): The T consistently focused on C’s emotions during the session. This might include
discussing emotions that arise in the session (e.g., “What emotion are you experiencing in this
moment?”), eliciting emotional responses when indicated (e.g., “You’re recounting that story in a
very matter of fact manner. Did you also experience some emotion?”), helping the C to observe and
describe components of their emotions (e.g., “It sounds like you were feeling fear. What did you
notice in your body? What action urges did you have?”) and formulating C’s problems as related to
emotion (e.g., deficits in emotion regulation skills, inhibited emotional experiencing). Emotion focus
differs from Informal Exposure (item #14) because it primarily involves helping Cs to observe and
describe their emotions and how they are related to problem behaviors, whereas informal exposure
involves actively and purposefully exposing Cs to emotions they are avoiding.
Non-adherent (0): The T would be non-adherent if no or too little attention was paid to emotion in
the session. This might include non-strategically ignoring C’s expression of emotion in session (e.g.,
not commenting on it or asking questions about it), attending superficially to C’s expression of
emotion (e.g., saying “you seem sad” without engaging in additional discussion about the emotion),
and/or not helping C to identify their emotion when needed (e.g., C says “I don’t know what I’m
feeling” and the T does not help them to describe it). If the T refers to emotion in passing or uses an
emotion word a few times, this would not be considered sufficient: the C’s emotions must be a
consistent focus of the session. Emotion focus would also fall below adherence if the T discusses
emotion dysregulation in a judgmental way or formulates the C’s core problems as due to factors
other than emotion (e.g., cognition or willpower).

II. PROBLEM ASSESSMENT STRATEGIES (Chapter 9 pp. 250 – 272)

4. DESCRIBE SPECIFICALLY (pp. 257 – 258)

*Required in every session of individual DBT

The essence of this item is that the T uses – and facilitates the C to use - behaviorally
specific language.

Adherent (1): Adherent delivery of this item means that situations, behaviors, emotions, and
cognitions should be described a) in a clear, precise manner (e.g., “I felt guilty” rather than “I felt
upset”) and b) without judgments (e.g., “They laughed at me” rather than “They were jerks”). T
should consistently model using behaviorally specific language and help the C to do so as well when
vague, judgmental, or extreme language is used. The T does not have to address every instance of
non-specific language to be adherent, but should do so more often than not.

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 Non-adherent (0): Insufficient behavioral specificity may include the T modeling vague or
judgmental language (e.g., calling C’s boss “a creep”) and/or rarely asking C to re-state judgments or
describe their experiences more specifically when vague language is used. This strategy may also fall
below adherence if the T does not help C to clearly specify problem behavior (e.g., the C reports
urges to “give up” or states that they “self-harmed” but the T does not elicit a specific description of
what this means).
5. CHAIN ANALYSIS (pp. 258 – 264)

The essence of this item is that the T conducts a chain analysis when needed to
understand the function of a problem behavior and the barriers to effective behavior.

Adherent (1): A chain analysis is needed when a high priority target behavior occurs and the
controlling variables for the behavior either have not been fully assessed or prior solutions
generated for the behavior were not effective. The T may also choose to conduct a chain analysis at
other times (e.g., for a low priority quality-of-life-interfering behavior). If a chain analysis is
conducted, it must focus on one specific episode of a behavior and achieve the overall goals of
understanding (1) the function of the problem behavior, and (2) what got in the waySi of more
effective behavior. This is done by attending to small units of behavior at the beginning
(antecedents), middle (the target behavior itself), and end (consequences) of the chain of events.
Typically, a chain analysis includes the following five components:
a) Vulnerabilities: Factors that made the C more vulnerable to engaging in this particular
instance of the target behavior
b) Prompting event: The event that set off this particular chain of events
c) Controlling links: The critical emotions, bodily sensations, thoughts, behaviors and/or
environmental factors that arose between the prompting event and the problem behavior
d) The problem behavior: Specifically described by its frequency (how often the behavior
occurred), duration (how long the behavior lasted), intensity (strength or amount of the
behavior), and topography (what the behavior looked like)
e) Consequences: Short- and long-term outcomes of engaging in the problem behavior

A chain analysis may be adherent even if it does not include all five components so long as it is
sufficiently detailed to achieve the overall goals (1) and (2) specified above. This item would also be
considered adherent if a chain analysis was not done because it was not needed (i.e., no high
priority target behavior occurred or the controlling variables were already known and solutions
were effective). When a chain analysis is not needed, it may be sufficient to ask a few clarifying
questions to understand what occurred.

Non-adherent (0): The strategy would fall below adherence if the T does not conduct a chain
analysis when needed (see above), if the chain lacks specificity (e.g., about the frequency, duration,
and nature of the target behavior), and/or if the chain was missing important details that made it so
that the function of the behavior and/or the barriers to effective behavior were not clear. Finally,
the chain analysis must focus on one instance of a behavior, not on a general pattern of problem
behavior.

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III. PROBLEM SOLVING STRATEGIES (Chapter 9 pp. 272 – 291 and Chapter 11 pp. 331 – 334)

6. TEACH NEW INFORMATION (pp. 272 – 275; 331-334)

The essence of this item is that the T taught the C new behaviors or skills and/or
provided psychoeducation about topics relevant to their behaviors.

Adherent (1): Adherent delivery of this item involves providing C with new information to help them
change and/or better understand their behavior when needed. This may be done by teaching or
modeling new behavior or skills using skill acquisition procedures such as instructing the C in a skill
to be learned, providing information on how a skill works, and modeling how to use a skill. This may
also be done by providing psychoeducation about relevant topics such as the biosocial model of
borderline personality disorder, evidence-based treatments, and behavioral theory. This item would
also be considered adherent if no new information was taught because it was not needed (e.g., the
C was already knowledgeable about relevant skills and topics).

Non-adherent (0): This item would fall below adherence if the C asks about or displays faulty
understanding of a skill (e.g., if the C says that crisis survival skills are supposed to make them feel
better) or is clearly lacking knowledge about a relevant topic (e.g., if the C believes that PTSD is not
treatable) and no new information is provided. Additionally, it would be non-adherent if a T teaches
a skill incorrectly (e.g., says that mindfulness requires the C to meditate), provides inaccurate
information (e.g., suggests that DBT is the only evidence-based treatment for borderline personality
disorder), or gives information that is inconsistent with the DBT model (e.g., presents the C’s desire
to die as being due to an insecure attachment style).
7. GENERATE SOLUTIONS (pp. 278 – 281)
*Required in every session of individual DBT

The essence of this item is that the T helps the C to generate and evaluate new solutions
to problems.

Adherent (1): This item would be considered adherent if solutions were generated that were
appropriate and well-matched to the C’s problems and current abilities. Solutions may include
specific DBT skills, other DBT problem solving strategies (e.g., contingency management, exposure),
as well as more general effective behavior, and should be thorough and sufficient (e.g., several
solutions are generated to address one or more core elements of the problem). For example, if C’s
problem is that they are about to be evicted from their apartment, solutions could focus on helping
the C to problem-solve (e.g., brainstorm ways to retain their current housing or find new housing) as
well as to tolerate the distress caused by this stressor without doing anything to make the situation
worse (e.g., crisis survival skills). It is preferable for the C to generate as many of the solutions as
possible, though sometimes this will not be feasible (e.g., when the C is not familiar with many skills;
when the C is in severe crisis). Solutions that are generated should be evaluated to ensure that they
are realistic and adaptive.

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 Non-adherent (0): This item would fall below adherence if no solutions were generated to address
the C’s problems or if the solutions that were generated were not well-matched to the C’s problems
or current abilities, inconsistent with DBT (e.g., examining transference), or unrealistic. For example,
in the above example of the C who is about to be evicted, if the only solutions that are generated
are to “find a job” or “borrow money from your parents” but the C has not worked or spoken to
their parents in years and rent is due by the end of the week, these are likely neither adequate nor
realistic. This item would also be considered non-adherent if solutions are not well-matched to the
C’s problem (e.g., suggesting the C “radically accept” being homeless when problem solving
strategies have not yet been tried) or are potentially maladaptive (e.g., suggesting the C threaten
their landlord with an unfounded lawsuit). Additionally, if the T generates most of the solutions
when it would have been possible for the C to do so, this item would not be adherent.
8. ACTIVATE NEW BEHAVIOR IN SESSION
*Required in every session of individual DBT

The essence of this item is that the T compels an active, new response from the C
in session.

Adherent (1): Activating new behavior in session can be done in a variety of ways (e.g., engaging the
C in role-playing identified solutions, pushing the C to dispose of lethal means in session, having the
C practice a new skill, compelling a non-responsive C to actively participate). At its core, this item
captures that the C is doing something differently in session, not just talking about doing something
differently. If the T makes a significant effort to drag out new behavior from the C during the
session, but the C does not perform the desired behavior (e.g., T makes the request more than once,
attempts to assess what is getting in the way, and highlights polarization), this item would still be
rated as adherent.
Non-adherent (0): Failure to activate or drag out new behavior from the C in session would bring
this item below adherence (e.g., the T highlights that the C’s judgmental language is a problem but
does not ask them to restate judgments in session). In addition, if the T attempts to elicit new
behavior from the C but does not pursue it if the C does not engage in the requested behavior, or
readily allows the C to engage in escape behavior, this item would also fall below adherence. For
example, if the T attempts to do a chain analysis about a recent hospitalization, the C refuses to talk
about what happened, and the T does not make further attempts to elicit the requested
information, this item would be non-adherent. Asking the C to engage in new behavior as
homework would not count; the new behavior must occur in session.
9. PROVIDE COACHING FEEDBACK (pp. 336 – 337)

The essence of this item is that the T provides behaviorally specific feedback to the C to
shape, refine, and increase the likelihood that the C will engage in skillful behaviors.

Adherent (1): When the C used a specific skill or generally engaged in skillful behavior, the T
provided coaching and feedback to clarify effective behavior and/or shape more effective use of the
skill. Feedback was behaviorally specific, which means that the T used concrete, precise language to
describe effective behavior and/or to coach the C on what needs improvement. For example, if the C

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 is practicing opposite action for shame, the T may say, ““Nice job speaking clearly. Can you try it
again while making consistent eye contact with me?” If no specific skill was used or there was no
need to shape and refine effective behavior, then coaching is not needed and this item would be
rated as adherent.
Non-adherent (0): This item would fall below adherence if a specific skill was used or behavior
occurred that was not fully effective and the T did not provide the C with any feedback on how to
improve their skillfulness. For example, if a depressed C succeeded in leaving the house every day
but said that it did not help because they spent the entire time ruminating about their problems, it
would be non-adherent if the T did not provide coaching to improve the effectiveness of this skillful
behavior. Additionally, this item would not be considered adherent if the feedback provided lacked
behavioral specificity (e.g., the T suggested that the C “stop ruminating” when outside the house but
did not provide specific feedback about how to do so).
10. GENERALIZE NEW LEARNING (pp. 337 – 343)
**Required in every session of individual DBT after pre-treatment

The essence of this item is that the T actively works to transfer skills, behavior, and
knowledge learned in therapy to the C’s real-world environment.

Adherent (1): This item would be considered adherent if the T gave at least one behavioral
assignment to practice or review new responses discussed in session in relevant contexts in the C’s
life. This may include assigning homework to practice a specific skill (e.g., paced breathing),
implement general solutions that were generated (e.g., schedule a doctor’s appointment), or review
new learning (e.g., listen to a recording of the session). Behavioral assignments should be specific
and tailored to the C’s problems and abilities.
Non-adherent (0): This item would be considered non-adherent if the T did not give at least one
behavioral assignment to practice or review new responses learned in therapy in the C’s everyday
environment. Behavioral assignments must involve specific tasks the C is asked to do outside of
therapy to generalize new learning. It is not sufficient to discuss solutions the C could implement
(e.g., “maybe you could try mindfulness of current emotion”) without specifically assigning them to
do so. Additionally, if behavioral assignments are not well-matched to the C’s problems (e.g., the C is
asked to practice the STOP skill to decrease anxiety) or abilities (e.g., the C is asked to use a skill they
have not yet learned) this item would be non-adherent.

11. COMMITMENT AND TROUBLESHOOTING (pp. 284 – 291; 281)

The essence of this item is that the T attempts to get a commitment from C when
needed and troubleshoots what might get in the way of doing what they agree to do.

Adherent (1): An attempt to get a commitment from a C is needed when: (1) the C is in pre-
treatment (commitment to work on targets and engage in DBT), (2) the C is suicidal or has engaged
in life-threatening behavior (commitment to not kill/harm self), and (3) the T and C have decided on
solutions or tasks the C will implement outside of therapy (commitment to complete behavioral

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 assignments). The T may use a variety of commitment strategies such as pros and cons, devil’s
advocate, foot-in-the-door, and door-in-the-face to the extent they are needed. If the C is clearly in
agreement with the T, a single explicit request may be sufficient (e.g., “You are committed to getting
rid of your alcohol as soon as you get home, correct?”). If the C does not agree to the requested
commitment, it would still be adherent as long as the T used commitment strategies thoroughly and
flexibly in an effort to obtain a commitment. If a commitment is obtained, it is required that the T
troubleshoot what might get in the way of the C doing what they have agreed to do. This typically
includes identifying potential obstacles to applying solutions and helping the C figure out how to
overcome them.

Non-adherent (0): This item would be considered non-adherent if: (1) a commitment was needed
(see above) but the T made no or too little attempt to obtain a commitment, or (2) a commitment
was obtained but no or too little troubleshooting was done. For example, if a C self-harmed in the
last week it would be non-adherent if the T either did not ask for a commitment to not self-harm
again or asked for this commitment but did not try other strategies when the C refused.
Additionally, if the C committed to not self-harming again but the T did not actively troubleshoot
potential interfering factors, this item would be non-adherent. Finally, if potential obstacles were
identified (e.g., the C says “I’ll try but I can’t promise I won’t self-harm if I get really stressed out”)
and the T does not help them to generate adequate solutions to keep their commitment (e.g., the T
says, “just do your best”), this item would also fall below adherence.

IV. CONTINGENCY MANAGEMENT STRATEGIES (Chapter 10 pp. 292 – 328)

12. REINFORCEMENT (pp. 301 – 302)

*Required in every session of individual DBT

The essence of this item is that the T reinforces the C’s adaptive behaviors.

Adherent (1): Reinforcement is defined as a consequence that increases the likelihood of a behavior
and should be the primary contingency management strategy used. This often includes expressions
of the T’s approval, praise, validation, or attention/contact from the T. The caveat here is that the
T’s behavior must be reinforcing to the C; thus, if the C is not reinforced by T’s warmth, then
increasing warmth in response to a C’s adaptive behaviors would not be reinforcement and other
strategies that are reinforcing to the C would need to be utilized.
Non-adherent (0): If the T provides too little or no reinforcement during the session, this item is
rated as non-adherent. Additionally, this item would fall below adherence if the T overuses praise
(e.g., such that it seems artificial or phony), or punishes or ignores adaptive behavior. For example, if
a C is recounting a skillful interaction with their boss, and the T fails to make eye contact or says,
“Why would you have said that?” in a harsh tone.

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13. AVERSIVE CONTINGENCIES (pp. 306 – 314)

The essence of this item is that the T applies aversive consequences/punishment to

decrease the likelihood of maladaptive behaviors.

Adherent (1): Adherent use of aversive contingencies may involve strategically removing a positive
(e.g., withdrawing warmth in a clear and noticeable way) or applying a negative (e.g., explicitly
expressing disappointment) in response to a maladaptive behavior. To count as an aversive
consequence, the T must clearly be using a negative consequence to decrease (punish) a specific
maladaptive behavior, rather than generally engaging in behavior the C may find aversive (e.g.,
interrupting the C, calling attention to dysfunctional behavior, dragging out new behavior). Aversive
contingencies can be applied informally (e.g., through facial expressions and body posture) or
formally (e.g., using correction-over correction). This strategy is needed when there is evidence of
maladaptive behavior and a) the reinforcing consequences of the maladaptive behavior are not
within the T’s control (e.g., the T cannot change the C’s physiological response to self-harm but can
reduce contact with the C as an aversive contingency for the behavior) and b) the maladaptive
behavior interferes with all other adaptive behavior (i.e., there is nothing to reinforce). If aversive
consequences are not needed and therefore not used, this item would be coded as adherent.

Non-adherent (0): Non-adherent use of this strategy may involve not applying aversive
contingencies when they are needed (e.g., not confronting C’s frequent hostility toward T) or
reinforcing maladaptive behavior (e.g., laughing when C is telling a story involving problematic drug
use). This item would also fall below adherence if an aversive contingency is used when another
contingency management strategy could be used instead (e.g., extinguishing maladaptive behavior
by ignoring it or reinforcing a desired behavior that is present) or is too harsh; for example,
impulsively putting a C on a therapy vacation without first specifying the behavior(s) that the C
needs to change or giving the C a reasonable chance to change the behavior(s).

V. EXPOSURE BASED PROCEDURES STRATEGIES (Chapter 11 pp. 343 – 358)

14. INFORMAL EXPOSURE (pp. 343 – 357)

The essence of this item is that the T explicitly uses exposure-based procedures to
treat extreme emotional responses or block emotional avoidance.

Adherent (1): Informal exposure is needed if emotional avoidance is a high priority target for the C
(e.g., based on C’s goals, case formulation, and target hierarchy for the session) and it is obvious
that the C is blocking or avoiding emotions in session. Informal exposure involves actively and
purposefully exposing the C to emotion(s) they are avoiding at least once during the session: it does
not have to be done every time the C avoids emotions to be adherent. In contrast to formal
exposure, informal exposure is typically brief and unstructured. In contrast to Emotion Focus (Item
#3) that typically involves observing and describing the C’s emotions, informal exposure involves
noticing and blocking emotional avoidance and coaching the C to experience the emotion without
avoiding for a period of time (e.g., several minutes). Adherent delivery of this strategy means the T
is utilizing all elements involved in conducting informal exposure including:

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 1) Noticing and confronting emotional avoidance (e.g., lack of emotion when discussing
emotional topics; emotional suppression; changing the topic; dissociation)
2) Identifying the emotion that was present and redirecting back to the cue
3) Coaching C to experience the emotion without avoiding
4) Blocking problematic action and expressive tendencies, including coaching in opposite
action as needed (e.g., if C slumps in the chair, ask C to sit up).
5) Continuing exposure until new learning occurs (e.g., C learns that the emotion can be
tolerated for longer than expected or that T will not punish crying). This may include
assessing C’s feared outcomes prior to the exposure task and/or asking for ratings of
emotional intensity before, during, and after the exposure task.

Non-adherent (0): This item would fall below adherence if the C is obviously avoiding or blocking
emotions in session and the T does not use informal exposure when emotional avoidance is a high
priority target. Additionally, this item would be rated as non-adherent if the T exposes C to an
emotional cue but does not block the C’s problematic action or expressive tendencies (e.g., allows
them to avoid eye contact when experiencing shame), ends the exposure prematurely (i.e., before
new learning occurs), or forces the C to engage in informal exposure against their will.

VI. COGNITIVE MODIFICATION STRATEGIES (Chapter 11 pp. 358 – 370)

15. CHALLENGE COGNITIONS (pp. 365 – 366)

The essence of this item is that the T confronts and challenges the C’s maladaptive
thoughts and judgments.

Adherent (1): Challenging cognitions is needed when there is evidence that the C’s maladaptive
cognitions are functionally related to target behaviors (e.g., the thought “my family would be better
off without me” occurs as a link in the chain prior to a suicide attempt) or having a severe negative
impact on the C (e.g., repeatedly thinking “I am stupid” is causing the C to feel intense shame).
Strategies may include directly confronting C’s maladaptive cognitions (e.g., “that thought is
completely inaccurate!”), using Socratic questioning (i.e., helping C to understand assumptions
underlying their thoughts and examine supporting or disconfirming evidence) and helping the C to
generate more adaptive and effective thoughts. Of note, there are also times in which a C’s specific
cognitions may be more effectively ignored than challenged (e.g., if T is targeting a higher priority
behavior; if evidence suggests that engaging with C’s maladaptive cognitions may reinforce them).
Non-adherent (0): This item would be rated as non-adherent if there is evidence that the C’s
maladaptive thoughts are related to important target behaviors or having a serious negative impact
on the C, and either no efforts were made to confront and challenge the thoughts or this was done
insufficiently (e.g., thoughts were commented upon, but no efforts were made to help the C re-
evaluate them). Additionally, if the T insists that their thoughts are the “correct” ones or assumes
that the C’s thoughts are “wrong” and does not work to find a synthesis and/or validate the C’s
point of view this item would fall below adherence.

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VII. VALIDATION STRATEGIES (Chapter 8 pp. 221 – 249)
16. VALIDATION LEVEL 4 (V4) LEARNING HISTORY/BIOLOGY

The essence of this item is that the T communicates that a C’s emotions, cognitions,
and/or behaviors make sense in the context of the C’s learning history or biology.

Adherent (1): Adherent delivery of this strategy involves communicating that a C’s response is
understandable based on learning history (e.g., a C was punished for expressing emotions as a child,
and therefore blocks emotional expression as an adult) and/or biology (e.g., a C experiences
particularly intense emotions because they are biologically more vulnerable to them). Statements of
validation must be sufficiently explicit, with T clearly and specifically linking C’s responses to learning
history or biology. For example, “It is entirely understandable that you’re afraid to cry in front of me
given that your parents punished you any time you expressed sadness.”

Non-adherent (0): This item would fall below adherence if the T did not explain how the C’s
emotions, cognitions, or behaviors were understandable in terms of past learning or biology when
these factors clearly influenced the C’s behavior or the C’s behavior was not valid based on the
current context (i.e., V5 was not possible). For example, if a C invalidated the fear they experience in
response to a trauma cue (e.g., “It's stupid that I get so afraid in parking garages”) and the T did not
offer validation based on the C’s learning history (e.g., “It makes total sense that you’re afraid given
that you were raped in a parking garage.”). Additionally, this item would be rated as non-adherent if
the strategy was used, but explanations were vague or oversimplified (e.g., “Because you have
borderline personality disorder, of course you have difficulty tolerating emotions”).

17. VALIDATION LEVEL 5 (V5) CURRENT EVENTS

*Required in every session of individual DBT

The essence of this item is that the T communicates that a C’s emotions, cognitions,
and/or behaviors make sense in the current context; that is, the C’s responses are
reasonable given the current situation.

Adherent (1): Adherent delivery of this strategy can include finding the kernel of truth in a C’s
perspective (e.g., “I know you call and text your boyfriend so frequently because you’re terrified of
losing him”), communicating that the C’s interpretation of a situation is accurate (e.g., “Your
perspective seems reasonable to me”), normalizing the C’s response (“Anyone would feel that
way”), and countering the C’s “should” (e.g., the C says “I should be better by now” and the T
responds, “It makes sense that there is still more work to do since you’ve only been in DBT a few
months”).
Non-adherent (0): As V5 is a required item in individual DBT, if it is not used, the item is rated as
non-adherent. Additionally, if the T uses V4 when V5 would have been possible, this item is rated as
non-adherent. For example, if the T says, “Of course you’re upset that your boyfriend left you given
your history of being rejected by those you care about” instead of “Of course you’re upset that your
boyfriend left you. Anyone would be devastated by this.”

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18. VALIDATION LEVEL 6 (V6) RADICAL GENUINENESS
*Required in every session of individual DBT

The essence of radical genuineness is that the T interacts with the C in an ordinary
and natural manner that conveys that the C is a person of equal status.

Adherent (1): A T who is radically genuine is one who acts spontaneously and authentically. This
means that the T remains their usual, genuine self within the therapeutic relationship and treats the
C as a person of equal status while delivering DBT.

Non-adherent (0): This item would be rated as non-adherent if the T is not at all or insufficiently
radically genuine. This may include presenting oneself in an overly professional manner, treating the
C as fragile, using an overly soothing voice tone, or conveying that the relationship is not one
between equals. Overall, if the T is not generally interacting with the C in an ordinary manner (e.g.,
as they would act with friends or family) this item would fall below adherence.

VIII. RECIPROCAL COMMUNICATION STRATEGIES (Chapter 12 pp. 372 – 392)

19. WARM ENGAGEMENT (pp. 383 – 388)

*Required in every session of individual DBT

The essence of this item is that the T communicates warmth and caring to the C.

Adherent (1): Warm engagement is the T’s default style in DBT and can include expressing caring
towards the C verbally (“I care about you”) and non-verbally (kind voice tone, making eye contact,
leaning forward).

Non-adherent (0): A T would fall below adherence on this item if they express irritation, appear to
not like the C, or behave in a generally cool manner when this is not being done strategically (e.g., as
an aversive contingency).

20. SELF-DISCLOSURE (pp. 376 – 382)

The essence of this item is that the T discloses information about themselves and/or
their reactions to C in session.

Adherent (1): Adherent delivery of this strategy may include T using self-involving self-disclosure to
share their reaction to C (e.g., “When you do X, I feel Y”), model coping with problems similar to Cs
(e.g., difficulty sleeping), and/or provide professional (e.g., degree, training) and personal
information (e.g., parental status, age). Any sharing of personal information counts as self-
disclosure: it does not have to be particularly sensitive or meaningful information (e.g., the T shares
their vacation plans). When self-disclosure is used, it must be within the T’s limits and with the C’s
best interests in mind.

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 Non-adherent (0): This strategy may be delivered non-adherently if the T discloses information that
is not relevant (e.g., how the T coped with a problem that was unrelated to C’s problems), models
coping ineffectively with failure (e.g., talking about how a specific DBT skill doesn’t work for T’s own
problems without suggesting effective alternatives), is excessive (e.g., too frequent), and/or overly
personal (e.g., sharing detailed information about one’s own divorce to a C who is going through a
divorce). In addition, this item can fall below adherence if self-disclosure was indicated and not used
(e.g., the C’s behavior was having a significant negative impact on the T, and the T did not articulate
this to the C).
IX. IRREVERENT COMMUNICATION STRATEGIES (Chapter 12 pp. 393 – 398)
21. DIRECT CONFRONTATION (pp. 393 – 396)

The essence of this item is that the T confronts problematic or dysfunctional behavior
when needed.

Adherent (1): Adherent delivery of this strategy requires that the T is confronting dysfunctional
behavior in a way that gets the C’s attention and conveys its seriousness. Direct confrontation is
needed when a C engages in a dysfunctional behavior and appears to not be taking it seriously (e.g.,
C jokes about driving while drunk) and/or it is a particularly egregious problem that must be stopped
(e.g., C punches the T’s office wall). Direct confrontation is not needed if dysfunctional behavior can
be effectively addressed using a different strategy (e.g., by providing coaching). Strategies can
include using a confrontational tone of voice, blocking a C’s attempts to avoid discussing a topic,
labeling a behavior as dysfunctional or problematic, or calling the C’s bluff. Confrontation must be
direct and explicit (e.g., “Drunk driving is going to kill you or someone else – this is a serious problem
that has to stop!”). Simply discussing a problem behavior as part of routine targeting (e.g., when
conducting a chain analysis) or highlighting the consequences of a problem behavior (e.g., “If you
keep driving while drunk, then you may hurt yourself or someone else”) is not considered
confrontation.

Non-adherent (0): This item would be rated as non-adherent if the strategy was needed and not
used. For example, if the C expressed high suicide urges with intent and the T did not emphatically
instruct the C to not act on them. Additionally, this item would fall below adherence if dysfunctional
behavior was addressed, but in a way that did not convey the seriousness of the behavior (e.g., the T
did not convey the urgency of changing the behavior or used a tentative or joking tone).
22. UNORTHODOX IRREVERENCE (pp. 394 – 395; 396 – 397)

The essence of this item is that the T uses unorthodox or irreverent strategies to help
get the C “unstuck” from dysfunctional responses.

Adherent (1): This item would be rated as adherent if the T uses irreverent responses when needed;
that is, when there is evidence that the C and T are “stuck” in a dysfunctional thought, emotion, or
behavioral pattern, and other strategies are not working. Irreverence can include saying something
unorthodox or unexpected, using humor, using a deadpan or dramatic style to contrast the C’s style,

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 assuming omnipotence (“I know what’s best for you”) or impotence (“I’m really not sure what you
should do next, I’m no expert!”), and oscillating intensity (e.g., alternating between talking loudly
and quietly). Irreverence can also be non-verbal (e.g., a raised eyebrow; throwing one’s hands up).
Being funny or humorous is only counted as irreverence if it served the function of helping to get the
C unstuck from dysfunctional responses.
Non-adherent (0): When the situation suggests that irreverence is needed and it is not used, this
item is rated as non-adherent. Additionally, this strategy would be rated as non-adherent if the use
of irreverence was mean-spirited (e.g., judgmental, unkind, pejorative) or sarcastic rather than used
as tool to help the C get unstuck.
X. DIALECTICAL STRATEGIES (Chapter 7 pp. 199 – 220)

23. BALANCED STYLE AND STRATEGIES (pp. 202 – 204)

*Required in every session of individual DBT

The essence of this item is that the T balances acceptance- and change-oriented
strategies and communication styles.

Adherent (1): This item is rated as adherent if the T appropriately balanced strategies (acceptance
vs. change; nurturing vs. demanding; flexibility vs. stability) and style (reciprocal vs. irreverent). This
does not mean that the T must conduct 50% of the session from an acceptance-oriented standpoint
and 50% from a change-oriented standpoint, but rather that the strategies and styles are being
deployed in a balanced manner depending on the context of the session. For example, if a C is
engaging in significant therapy interfering behavior, a T may utilize more change-based strategies to
target these behaviors. However, if a C is grieving the death of a friend, a T may utilize more
acceptance-based strategies. In both cases, the T may be appropriately balancing style and
strategies, but the context of the session suggests leaning more heavily on one set of strategies than
the other. When rating this item, it is important to consider the session as a whole rather than any
particular portion of the session (e.g., T may be change-heavy when addressing one problem and
acceptance-heavy when addressing another).

Non-adherent (0): This item is rated as non-adherent if the T falls too heavily on one set of
strategies (e.g., the T pushes strongly for change without offering sufficient validation) or if the T
rapidly alternates between strategies in a chaotic and/or non-strategic manner.
24. MODEL DIALECTICAL THINKING* (pp. 204 – 205)
*Required in every session of individual DBT

The essence of this item is that the T models dialectical thinking and works to find a
synthesis when polarization occurs.

Adherent (1): Adherent delivery of this strategy can include modeling both/and thinking (e.g.,
“Completing your diary card elicits painful emotions you would prefer to avoid and it helps us to
better understand the problems that are causing your emotional pain”) and/or a dialectical world

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 view (e.g., allowing for natural change, suggesting that truth evolves over time). Additionally,
adherent use of this strategy includes highlighting polarization when it occurs, searching for what is
being left out, and working towards synthesis (e.g., “You keep insisting that you’re to blame for this
situation, whereas I feel absolutely certain you are not. What are we going to do about this?”).
Non-adherent (0): Modeling dialectical thinking is a required strategy and thus if it is not used, this
item should be rated as non-adherent. Additionally, if a both-and statement is used, it must
represent an actual dialectic: linking two unrelated or non-opposing statements together with an
“and” (i.e., attempting to create a dialectic where there is none such as “You’re experiencing intense
sadness and you’re experiencing intense fear”) would not be considered modeling dialectical
thinking. Similarly, if the T says things that conflict with a dialectical world view (e.g., uses absolute
statements about what is “right” or “wrong”), this would be non-adherent. Finally, if polarization
occurs and the T does not try to find a synthesis that acknowledges the validity in both sides, this
item would also be rated as non-adherent.
XI. CASE MANAGEMENT STRATEGIES (Chapter 13 pp. 399 - 434)
25. CONSULTATION TO THE CLIENT (pp. 406 – 421)

The essence of this item is that the T consults to the C about how to interact effectively
with their environment rather than intervening in the C’s environment on their behalf.

Adherent (1): Adherent delivery of this strategy involves helping the C act as their own agent in
managing their environment (e.g., getting information from other professionals, advocating for their
needs with family members). Consultation-to-the-client is appropriate when the C can be coached
to interact effectively with their environment and the long-term outcome (e.g., building skillfulness)
is more critical than the short-term outcome (e.g., the C is not in immediate crisis). This strategy is
only relevant to other professionals and key people in the C’s life with whom it may be typical for a T
to have direct contact (e.g., people with knowledge of the details of the C’s mental health
treatment), but the T coaches the C to interact with them instead. For example, consultation-to-the-
client could be used when a C raises a concern about their skills group leader or parent, but would
not apply to coaching a C about how to interact with a friend or neighbor who is not involved in the
C’s treatment. Efforts to help the C interact effectively with people with whom it would not be
typical for the T to interact (e.g., coaching them to use DEAR MAN to ask their boss for a raise)
would be coded under Generates Solutions (item #7).
Non-adherent (0): Ts are expected to use consultation-to-the-client as their default case
management strategy; thus, if the T intervenes directly in the Cs environment when it would have
been possible to consult to the C about how to do so or involve the C in these conversations, this
item should be rated as non-adherent. Examples of directly intervening in the Cs environment might
include interacting with other professionals or individuals in the C’s life without the C’s permission
or presence (e.g., instructing other providers in how to interact with C), sending reports about the C
without the C’s review, and speaking on the client’s behalf during a family session rather than letting
them speak for themselves.

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XII. PROTOCOLS (Chapter 15 pp. 462 – 519)
26. SUICIDAL BEHAVIORS PROTOCOL (pp. 468 – 495)

The essence of this item is that the T uses the DBT suicidal behaviors protocol, including
assessment, problem-solving, commitment, and troubleshooting, when it is needed.

Adherent (1): The suicidal behaviors protocol is required if suicidal or non-suicidal self-injurious
behavior, or a significant increase in urges (≥3 points out of 5 on the diary card) to engage in these
behaviors, has occurred since the prior session. There may also be times when the protocol is
indicated even if a behavior does not meet these criteria (e.g., a C reports a “2” on urges for suicide
after several months of reporting only 0’s). Adherent delivery of this strategy means that all
elements of the suicidal behaviors protocol were utilized, including (1) assessment of the behavior
and/or increased urges (e.g., via a chain analysis), (2) problem-solving to prevent future suicidal or
self-injurious behaviors, (3) commitment to a non-suicidal behavior plan, and (4) troubleshooting
the behavior plan.
Non-adherent (0): This item would be rated as non-adherent if there was evidence that the C
engaged in suicidal or non-suicidal self-injurious behavior since the previous session, or had
experienced a significant increase in urges to engage in these behaviors, and the T did not use the
suicidal behaviors protocol. Utilizing some of the elements (e.g., assessment of the behavior but no
problem-solving, commitment, or troubleshooting) would also bring this item below adherence. If
the suicidal behaviors protocol was non-adherent, the individual strategies that make up the
elements of the protocol may also be rated as non-adherent. For example, if commitment and/or
troubleshooting was not done as part of the suicidal behaviors protocol, then item #11
(Commitment and Troubleshooting) may also be rated as non-adherent. The same may be true for
item #5 (Chain Analysis) and #7 (Generate Solutions). In general, the individual items that
correspond to elements of the suicidal behaviors protocol should be rated according to the
guidelines for those items.

XIII. OVERALL EVALUATION

27. Total score
A total score can be computed by summing the 26 items (possible range = 0 – 26). Importantly, this
score should not be interpreted to indicate a therapist’s actual adherence to DBT unless it is
completed by an observer who has been formally trained to reliability. When completed by a trained
observer, a score of 23 or higher can be considered “adherent.” When completed by therapists as a
self-report measure or by observers without formal training, the score can be viewed as the
person’s best estimate of the therapist’s adherence.

28. What is your global impression of the degree to which the session was adherent to DBT?

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 This item is rated on a scale of 1 – 5 and should be answered after completing the 26-item checklist.
It is meant to capture the rater’s subjective assessment of how adherent the overall session was to
DBT.

29. How representative was this session of the T’s usual practice of DBT?

When answering this item, the rater should consider other sessions the T has had with this
particular C as well as with different Cs. Is this session typical of T’s usual delivery of DBT? Or was it
atypical or unusual in some way?

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